Over-Prescribing of Antipsychotics in Nursing Homes

Are pharmacy benefit managers to blame for the overuse of atypical antipsychotics in long-term care facilities?

MedPage Today reports that Sens. Charles Grassley (R-IA) and Herb Kohl (D-WI) “have urged the Centers for Medicare and Medicaid Services (CMS) to take a closer look at potential over-prescribing of atypical antipsychotics to nursing home residents.” In a letter to CMS administrator Donald Berwick, MD, Grassley and Kohl request “that CMS investigate what role pharmacy benefit managers—who manage prescription drug coverage for Medicare beneficiaries living in nursing homes—play in fueling the possible overuse of atypical antipsychotics in elderly people in long-term-care facilities.” MedPage Today notes, “The letter is a follow-up to one the senators sent in May after the release of the OIG report, which the senators themselves requested.’"

I find this news item very interesting. The Medicare program has been strengthening the oversight of drug therapy in nursing homes and now a “consulting pharmacist” is required to review a nursing home patient’s medication record monthly. If atypical antipsychotics are being overprescribed, it raises a few questions in my mind. Is the failure with consulting pharmacists who are not recommending the termination of these drugs when used inappropriately? Or does the failure lie with the physician or staff member who overrides the recommendation to discontinue the therapy?

This news item suggests that Grassley and Kohl think PBMs may play a role. I thought PBMs were interested in not paying for unnecessary drugs, so how do they increase the usage of antipsychotics if they are not indicated? Could the problem be related more to the desire to treat dementia with anything even if it is not likely to work? Can you help me understand what may be going on here?